This proposal will determine the impact of specialist palliative care on patient-centered outcomes and the quality of cancer care among advanced stage lung cancer patients. In addition, barriers and facilitators to integration in clinical practce will be explored. Specialist palliative care decreases patients' symptom burden and improves quality of life, but it is underutilized in clinical practice. The National Cancer Policy Board has defined poor-quality cancer care as when practices of known effectiveness are being underutilized. Important knowledge gaps in current palliative care research contribute to this underutilization. The central hypothesis is that early, integrated specialist palliative care improves outcomes and the quality of cancer care among advanced stage lung cancer patients. In a mixed-methods approach, the association between palliative care referral and healthcare utilization and patient mortality will be determined. For the first time, variations in the processs of palliative care and their association with variations in the quality of care will be determined. Providers' perceptions of barriers and facilitators to integration with usual lung cancer care will be explored. All of these studies will be conducted in the national Veterans Affairs healthcare system utilizing a robust cancer registry and comprehensive patient care databases. The results from this proposal will inform the development of an effective palliative care model for implementation in healthcare systems. This model is expected to be applicable to integrated healthcare systems and may eventually be tested in other advanced cancer patient populations. The rationale that underlies the proposed research is that it has the potential to diminish factors that have decreased uptake of palliative care and substantially impact the lung cancer treatment paradigm. This proposal has significant potential to identify interventions that could improve care delivery, enhance end- of-life experiences, and promote greater utilization of palliative care in clinical practice. This proposal is relevant to the mission of the National Cancer Institute to support research concerned with the treatment of cancer and the continuing care of patients and their families. This research is one component of the principal investigator's K07 career development plan that demonstrates a logical scientific progression towards research independence with the ultimate goal of obtaining R-level funding by the end of the award period. A detailed plan for scientific skill development and obtaining proficiency as a mixed-methods researcher are included in this proposal. Lending evidence to the feasibility of this proposal is the supportive research environments at Oregon Health and Science University and the Portland Veterans Affairs Medical Center. Research progress and career development will be overseen by a select group of senior investigators, and supported by the Health Services Research & Development center and the Oregon Clinical and Translational Research Institute Scholar's Program for early career investigators.